Provider Demographics
NPI:1033607189
Name:KOHANGHADOSH, FARIBA (DDS)
Entity type:Individual
Prefix:
First Name:FARIBA
Middle Name:
Last Name:KOHANGHADOSH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10476 LINDBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-3330
Mailing Address - Country:US
Mailing Address - Phone:310-266-6101
Mailing Address - Fax:
Practice Address - Street 1:18433 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4108
Practice Address - Country:US
Practice Address - Phone:818-882-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45379122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist